AFRICA

ERITREA

Eritrea's low GDP and small population contribute to the country's trouble creating a strong enough platform to address the population's needs. The country gained self-determination from Ethiopia in 1993, and has made improvements regarding mental health since, but the priority of its health budget has been physical care and not creating mental health institutions. The country now allocates a reasonable 5% of its mental health budget to mental health, but 93% of that amount goes to the country's one mental hospital.1

Access & Human Resources

Eritrea has very limited human resources to deploy in its mental health system. The number of total human resources is 0.83 per 100,000, including 0.06 psychiatrists (2 total nationwide), 0.06 other medical doctors (2 practicing non-psychiatrist physicians), and 0.03 psychologists (1 psychologist nationwide). The Journal of Eritrean Medical Association cited this human resource shortage as the greatest bottleneck to improved care, and that for each one psychiatrist in the developing world there are 180 in the developed world.2 All four of the psychiatrists and other doctors work in the public mental hospital. The country has one mental hospital, primarily staffed by a variety of nurses and health assistants holding the other 47 jobs.3

There are neither any mental hospitals, nor any psychiatrists, nor any psychiatric nurses practicing outside of the capitol city.4

Eritrea has made an effort to increase training, but the accelerated training could be detrimental in the long run. The Ministry of Health has begun to train 60 primary care workers in basic mental health knowledge, giving one week courses to nurses and physicians to train them to diagnose the most common mental disorders. However, the Ministry offers no follow-up supervision, making it difficult for the workers to have their diagnoses reviewed. There is also little ability for these new staff members to prescribe mental health drugs because of the country's weak psychotropic drug distribution capacity.5 Additional training has been put in place to train more psychiatric nurses for roles in community mental health. However, the poor access to psychotropic drugs may stifle new efforts to decentralize the mental health system.

The poor availability of psychotropic drugs has rendered their free access moot. The combination of poor drug access, limited facilities, and cultural factors lead only 3% of those with mental illness to receive care. This 97% treatment gap is well above the global average range of 76%-85%.6

Culture

The somewhat archaic management and organization of mental hospitals is worrisome for human rights. There is one residential facility in Eritrea's capital city of Asmara for 150 chronic patients. It is operated by the local government and not integrated with the Ministry of Health, and is primarily run by health assistants. The lack of specialized professionals present at this facility could make it susceptible to human rights abuses or a failure of monitoring. This system is particularly troubling because of Eritrea's poor national human rights record, particularly its repressive government and disinterest in allowing access to outside countries.7

There is no human rights review in mental health facilities and no emergency preparedness plan. 36% of admissions to mental hospitals are involuntary, and 33% of patients in mental hospitals are physically restrained at any point in time. 22% of patients spend five or more years in the hospital; it is unclear to what extent, if any, their cases are regularly reviewed.8

Those with mental illness are often directed towards prayer and spending time with family. Traditional healers are also consulted when mental health problems arise.9

There is a coordinating body for public education, and both government agencies and NGOs have hosted awareness campaigns. These campaigns have not chosen to collaborate with other groups, such as primary or adolescent health, within the Ministry of Health. The government has created legislative provisions regarding the mentally ill. Provisions for equal employment are not enforced, but provisions for access to state subsidize housing are enforced.10

ETHIOPIA

Ethiopia has made legislative strides to improve its mental health access and awareness, but has failed to demonstrate the political will to live up to those standards. The WHO is concerned with a "lack of awareness of the importance of mental health in [Ethiopia's] overall development."11 15% of the country suffers from a mental illness. Ethiopia spends 3.4% of its GDP on public health, with 1.7% of that going to mental health. Currently, 77% of Ethiopians have access to general public health, and 50% of children are fully immunized.12

Access

65% of those who attend mental health service have free access to the essential psychotropic medications. For those paying out of pocket, the cost of antipsychotic medication is 3% of the daily minimum wage, while antidepressants are 6% of daily minimum wage. There are no social insurance plans that cover health.13 These drugs can be prescribed by all primary care physicians, and primary care nurses have some ability to prescribe, with restrictions.14 Psychotropic drugs are not always available: between 50%-80% of primary care physicians have consistent access to drugs from each of the five main categories (anti-psychotic, antidepressant, mood stabilizer, anxiolytic, and antiepileptic).15

Long term facilities are also not always accessible, with only one mental hospital and one residential facility for the mentally ill. Ethiopia has found success creating an equitable system, though, with mental health services equally accessible to members of linguistic, ethnic, and religious minorities.

In 2006, Ethiopia made plans to create a National Mental Health Institute to open in 2009. Little has been reported since 2009, when the institute was in an early phase. Of note are the goals of the institute, which highlight the direction Ethiopia is hoping to take its health plan. This includes:

Overseeing training, service planning, and monitoring

Reform the Federal Ministry of Health to create a state-owned pharmaceutical fund, increasing access to psychotropic drugs at public health facilities

Continue mainstreaming of mental health care (initiated in 2005)16

The proposal also hopes to address a shortage of human resources through foreign collaboration and a shortage of medication through more consistent funding agreements with regional health bureaus.17

Health Professionals & Rural Care

There is a lack of human resources in the mental health field. This begins with university training: only 2% of doctor training and 3% of nurse training addresses mental health. There are only 0.02 psychiatrists and 0.3 psychiatric nurses per 100,000 Ethiopians, with a dangerously low 1.2 total mental health workers per 100,000.

The lack of staff is exacerbated by the urban-rural divide of mental health care. All eleven of the psychiatrists work in the capital city of Addis Ababa.18 Also, the density of nurses per capita is eight times greater in the capital city than elsewhere, and all of the mental hospital beds are located in or near the capital. However, 82% of the country lives in rural areas, predominantly working as farmers.

Culture

There is no legislation to protect the mentally ill against work discrimination, but recent law allows for a psychiatrist's testimony to reverse an employer's actions of discrimination in the workplace. There is also no housing provision for homeless who are mentally ill.19 The ministry of health is the only body that reviews mental hospital, a concern for those who want an external human rights review of facilities. One strength of the human rights system in Ethiopia is that all mental health staff, 30% of community-based outpatient staff, and 16% of community in-patient staff have received at least a one-day workshop on human rights. This is stronger human rights training than in countries with systems comparable to Ethiopia.20

Ethiopia has seen increased promotion of mental health public education and awareness since 2000. Government agencies, including mental hospitals, the Department of Health Education, and mass media have promoted mental health, with outside support from private newspapers and magazines.

NIGERIA

Nigeria's mental health system is a primarily government-run, urban-based system plagued by a lack of specialized medical professionals and culture of stigma and myth surrounding mental health. The prevalence of mental illness in the general public stands between 20% - 28%. Nigeria allocates 3.3% of its health budget towards mental health, falling below the WHO recommendation of 5% minimum allocation and global tendency to allocate up to 15%.21

Policy

Nigeria created a mental health policy in 1991 that outlined primary goals for the country. That list included plans to do the following:

Integrate mental health into general health

Decreasing stigma, focusing on positive attitudes in general public

Ensure equal rights to treatment for those with mental illness as those with physical illness

Emphasize access to care for minority groups22

This policy has struggled to be implemented in part because there is no government position specifically in charge of mental health. Rather, the duties regarding mental health are overseen by ministry officials with other primary positions.23 As of April 2012 a draft of a Mental Health Bill has been submitted to the National Assembly, but has not yet been passed into law.24 It is unclear at this time exactly how that bill would help implement previously legislated policy.

Access

33% of the Nigerian population has free access to health care. The national health insurance plan was intended to provide short-term coverage for those with mental disorders, but that has not been the case in practice. As of the WHO's report in 2006, most people with short-term meeds were paying out of pocket. 25 There is strong availability of all drugs at the outpatient facilities, with at least one drug of each primary class available year-round (rural access is more difficult: See Below.) The cost of antipsychotics is 7% of the daily minimum wage, and the cost of antidepressants is 5% of the daily minimum wage. The availability of drugs is limited over time, though, as there is a maximum duration of treatment set at 21 days for many cases.26

There are also concerns that access is impeded by the strong government presence in the mental health system, although scholars do not overtly address this. All seven mental health facilities are government-owned, and 95% of the psychiatrists in the country work exclusively for government health facilities.27 This leaves very little financial and human resources for other facilities; for instance, only 5% of psychiatrists work for the NGOs, for-profits, and unaffiliated mental health clinics in the country. There are also zero mental health professionals posted in primary or secondary schools.28

There is a very limited pool of highly trained and concentrated human resources in the country. There are 11.37 mental health workers per 100,000 members of the general population. The majority (8.03 of 11.37) fall under the category of "other mental workers." There are a mere 0.15 psychiatrists and 0.07 psychologists per 100,000 Nigerians. The ratio of Nigerians falls well below the WHO's minimum recommendation of a minimum 0.4 psychiatrists per 100,000. These low numbers are in part due to the migration of psychiatrists: 25% of psychiatrists leave Nigeria within five years of completing training.29.30

Rural vs. Urban

Access and awareness of mental illness is rare in rural regions. The density of beds in mental hospitals is highest in Lagos, the most populated city in Nigeria, and all of the countries eight mental hospitals lay in cities. For those living rural regions to pursue care, many would have to leave their state to reach the closest mental hospital.31 Many in rural areas have trouble even getting a diagnosis, though, because primary health care in rural areas normally excludes mental health services. Early, accurate identification of mental illness is rural areas is rare.

Culture

70% of Nigerians with mental illness seek care through non-orthodox means of healing, primarily religious groups or traditional healers.33 Traditional beliefs of illness and healing are still predominant in Nigeria. The common belief is that witchcraft, voodoo, and ancestry cause schizophrenia, and only wizards, voodoo priests, and other ancestors can heal the illness.34 Other mental illnesses are attributed to "wrong" lifestyles, including smoking marijuana. These beliefs are prevalent across society, with many members of the highly educated classes believing in traditional medicine as well.35

Mental illness is addressed by witch doctors through means including confinement, exorcism, flogging, chaining, and giving concoctions that sedate violent patients.36 The treatments provided by psychiatrists are looked down upon, as well as the professionals themselves. Many psychiatrists are shunned or avoided because of the fear that mental illness is communicable, and that psychiatrists will pass on mental illness to their children. This fear of communicability also leads many family members to avoid placing family members in the care of mental hospitals, to avoid them being surrounded by other "mentally derailed persons."37

Hospitals have trouble maintaining standards of those who are admitted to their care. Human rights laws were set in place in 1995, but no monitoring activities for mental hospitals or community facilities were set in place. 64% of all mental hospital admissions are involuntary, meaning they are initiated by families and resisted by patients.38 Only 14% of all mental health staff has received any human rights training. Officers do conduct visits to prisons, though, to ensure conditions there.

Education and awareness is an uphill battle. There is a notable negative depiction of the mentally ill in media coverage.39 While groups in and outside of the government have made efforts at times to educate the public, there is no government or independent body overseeing education campaigns and no structure for inter-agency cooperation.40 There is some expectation that psychiatric nurses would work in this field, but their full workload prevents them from contributing strongly to building awareness.41

SUDAN

Health has been named Sudan's national primary concern, but the country's investment is almost entirely in physical care. The lack of human and financial resources to address epidemic diseases has made consistent mental health care difficult to find and afford in non-emergency situations. There have been calls for prioritization of mental health care in the new country of South Sudan, with the hope that psycho-social care can help foster development.42 It is yet unclear if those changes will be made in the new state.

Access

Sudan has strong legal access to mental health medicines, but there are many situations in which rightfully obtaining drugs is costly and difficult. Every citizen has free access to essential psychotropic medicines, but only in situations deemed psychiatric emergencies. Otherwise, they must pay out of pocket. Out of pocket expenses are relatively very high, with antipsychotic drugs costing 27% of the daily minimum wage and antidepressants costing 18% of the daily minimum wage43. This would likely be considered unaffordable by many Sudanese. For those who do have a psychiatric emergency, though, drugs can be readily accessed in outpatient facilities, with all facilities having at least one form of each psychotropic drug.

There are 0.92 mental health workers per 100,000 Sudanese, with 0.06 psychiatrists and 0.09 non-psychiatric doctors. These numbers do not seem likely to increase in the immediate future, as very few students are graduating from medical schools with a specialization in mental health. 50% of the workers are practice in the government-run care, 21% in private care, and 29% in both. This is a more evenly balanced distribution than in comparable countries. The private practices, though, are largely unregulated, especially the work of psychologists.44

The form of care is heavily skewed towards inpatient care. There are neither systems in place that promote follow-up treatment nor mobile mental health facilities.

Rural Care

Drugs are most easily accessed in or near the capital city of Khartoum, and both the mental health hospitals are located in Khartoum. 80% of psychiatrists are located there, despite only 18% of the population living in Khartoum.45

Culture

Human rights are of concern, as there are no systems in place to monitor or report violations. There is no national human rights review body, and any review of protection is inconsistent. Also, the mental health staff members working in mental hospitals are untrained in human rights practices.46

There is no legislative support for those with mental illnesses. Mental health groups also have weak or nonexistent connections with other social services, making it difficult for mental health workers to help their patients navigate the fields of employment, housing, and welfare.47 There is also no body that oversees awareness or education efforts surrounding mental health.

Those who do have a mental illness are oftentimes neglected and abandoned, in part because of the cultural belief that their mental illness is a result of witchcraft. Some end up in prison and are mistreated, for fear that they are dangerous. One prisoners' rights advocate says they are "treated like wild animals." From a group of 60 individuals he believes are imprisoned for their mental illnesses, the advocate is particularly worried about 13 who have been imprisoned for over twenty years and whose health have steadily dwindled.

42 The New Nation, “South Sudan Government Asked to Prioritise Mental Health,” Oct 1 2011. http://www.thenewnation.net/news/34-news/189-south-sudan-government-asked-to-prioritise-mental-health.html43 World Health Organization, “Mental Health System in Sudan,” WHO-AIMS REPORT (2009): 5.44 WHO 19.45 WHO 24.46 WHO 5.47 WHO 6.